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DHR Form EO 001 - Complaint Form <br />(Please use additional sheets as necessary) <br />❑ Retaliation (please indicate below): <br />❑ I filed a complaint under the Anti - Discrimination and Harassment <br />Policy on (date). <br />❑ I requested a reasonable accommodation based on <br />on (date). <br />❑ Other (please identify): <br />I believe I was discriminated against in <br />❑ my employment status with the ❑ a program or service which the <br />County, or County provides. <br />Complaint Allegations <br />Date occurred: <br />Location: <br />Please describe what happened: <br />Time: <br />Who was involved? (Names and other identifying information) <br />Page 2 of 5 Rev. 02/08/12 <br />